1. Diagnosis And Treatment Of Prescription Opioid Dependence Steven W. Clay, D.O. Associate Professor, Department of Family Medicine Ohio University College of Osteopathic Medicine Athens, OH 45701

2. Overview 1. Goals of Our Out-Patient Program 2. Presenting the Program 3. Diagnosis 4. Buprenorphine 5. Results So Far

3. 1. Goals of Our Out-Patient Program Turning Lives Around –Detoxification from Prescription (& Illicit) Opiates –Involvement in 12 Step / Other Programs –Treatment of Co-Morbidity

4. Rural Ohio Setting Medicaid or No Insurance In-Patient Programs: Not Interested Out-Patient Treatment: Maybe Available in Several Weeks to Months Drug Screens Only With Cash Up Front 20 + Twelve Step Meetings Per Week (Alcohol or Drugs OK)

5. 2. Presenting the Program “Our services in Addiction Medicine are limited to those needing help with: –1. Possible substance abuse or addiction. –2. Getting off addictive drugs with as little discomfort as possible. –3. Buprenorphine treatment for narcotic addiction recovery.”

6. Weeding Out “We are NOT a pain treatment center.” “We are NOT an in-patient drug treatment center.” “We REQUIRE you to have a personal physician or we will help you find one.” “We REQUIRE a signed written treatment contract.”

7. The Rules Patients Must follow the rules we set Including: –Attendance at counseling –Attendance at 12 Step meetings” Those who break the contract will no longer be seen at our office. “If you are NOT prepared to follow the Rules, come back when you are ready!”

8. Patient Education Detox. Only: 97% Relapse By 1 yr. Reasons for becoming an addict: –Genetic, Environmental –Need to Re-Learn How to Live Without Drugs Need for complete treatment: –12 Step & Other Support

9. 3. Diagnosis of Addiction Disorders Risk Factors Interview Collateral Information Establish Use and Consequences Coexisting Physical / Psych Dz. DSM-IV / Other Diagnostic List

10. Addiction Diagnosis Dependence / Addiction: -Preoccupied with Acquiring / Use -Compulsive use Despite Adverse Consequences -Chronicity and Relapse

11. Establish Readiness For Change 1. Pre-Contemplation 2. Contemplation 3. Preparation 4. Action Prochaska and DiClemente Stages and processes of self-change of Smoking…J of Consult and Clin Psy 1983

12. Treatment Matching ASAM Criteria For Treatment Matching: –Consequences of Use –Family / Other Support –Financial Support –Physical / Psychiatric Co-Morbidity –Relapse Potential Mee-Lee and Shulman The ASAM Placement Criteria and Matching Patients to Treatment in Principles of Addiction Medicine 2 nd Ed. ASAM 2003

13. Treatment Matching Office Follow-Up to In-Patient Treatment Based Upon Illness Severity Most Followed as Out-Patients Due to Unavailable: –Treatment Centers –Money –Insurance

14. Prescription Opiate Addiction Patient Presentation In Contrast to Alcohol / Other Drug Addiction Patients: –Opiate Addicts Frequently Admit Problem and Ask for Help. –Friends, Family Refer Patients –The Word Goes Out in the Addiction Community

15. 4. Buprenorphine Subutex: –Buprenorphine SL Suboxone: –Buprenorphine / Naloxone SL –4 / 1 Ratio Buprenorphine Clinical practice Guidelines SAMHSA 2000

16. Buprenorphine Opioid Partial Agonist High Affinity Mu Binding Will Displace Many Other Opiates Maximum Effect About 30-40 mg Methadone Equivalent SL Absorption Acceptable Buprenorphine Clinical practice Guidelines SAMHSA 2000

17. Naloxone Opioid Antagonist Will Displace Other Opiates and Initiate Withdrawal Poor SL Absorption If Taken IV With Buprenorphine, Will Negate Agonist Actions Buprenorphine Clinical practice Guidelines SAMHSA 2000

18. Transfer to Buprenorphine Last Week Dose Is What Counts From Methadone: Taper By Program: –5-10 mg Per Week of Daily Dose –Goal 30-40 mg Per Day From Oxycodone (etc.): –Many Stop or Taper Before Being Seen –Adjust Daily Dose to PO Equivalent –Snorted (X 0.6), IV (X 1.5)

19. Transfer to Buprenorphine Suboxone Used Initially: –Less Risk in Office (Theft) Half to One 8/2 SL Tablet After: –48 Hrs. Without Methadone –24 Hrs. Without Oxycodone (Etc.) Follow With 8/2 to 16/4 SL Daily Information Given and Contract Signed

20. Follow-up Care 1-2 Weeks Initially MUST: –Go To 12 Step Meetings –Keep Appointments –Not Use Occasional Dosage Adjustments Then Seen Monthly

21. Non-Compliance Relapse is Part of the Disease Most Admit Mistakes I Usually Will Give One Second Chance Look For Progress Not Perfection Limited Use of Urine Toxicology Screens Due to Cost

22. Tapering Buprenorphine Decrease By ½ Dose Monthly Some Can Rapidly Come Off: 1-2 Weeks Some Take Months Variation Based on Patient Preference and Involvement in 12 Step Programs

23. 5. Results So Far

24. Results So Far Opiate Addicts Presenting to University Medical Associates Addiction Medicine Inclusion Criteria: –Opiate Use > 20mg / Day Methadone –Non-Pregnant –Willing to Follow Rules 41 Consecutive Opiate Addicts Placed on Buprenorphine

25. Results Mean Age 33, Range 18 to 56 63% Male -SAMHSA 2002 Drug Use Survey: Illicit Drug Use 62.1% Male Mean Methadone Equivalent Dose Per Day = 88.5 mg

26. (%) Family History: Alcohol, Drug & Psych Disorders

27. Psychiatric Diagnosis (%)

28. Drugs/Pain Prior to Opiates (%)

29. Opiate Progression (%)

30. Opiate of Choice (%)

31. Administration Route (%)

32. Detoxed. Before Treatment (%)

33. 12 Step Attendance (%)

34. Results (%)

35. O.B.O.T. in S.E. Ohio Mean Age 33 63% Male Mean Methadone Equiv. 88 mg 34% Negative Family History Addiction/Psych Disorders 54% Some Mental Illness

36. O.B.O.T. in S.E. Ohio 80% Common Drug Use Progression 90% Prescription Addiction 75% No Previous Detoxification 64% At Least Tried 12 Step Programs 63% Tapering or Completed Program 37% Relapsed or Presumed Relapsed